The Alliance Health Home Pilot
Since its inception, Roots has served Oakland residents experiencing homelessness and unstable housing. In 2015, in partnership with the Alameda County Department of Public Health’s Healthcare for the Homeless Program, Roots’ built upon this work to implement the Oakland Street Team Outreach Medical Program (STOMP), a physician-led street outreach healthcare team serving the homeless across Oakland. Our homeless services reflect the experience, expertise, and wisdom we have earned working with this population. In the past year, OaklandSTOMP has reached thousands of homeless Oakland residents through outreach, supply distribution, provision of medical care when needed, and by acting as a hub organization that links homeless individuals with a multitude of services. We are a key partner in the County’s network of health centers and community based organizations that increase access and improve care for homeless individuals, and are one of two organizations in the County contracted to provide Street Medicine.
The STOMP team, composed of our Street Medicine Director (a primary care physician), a Medical Assistant/Phlebotomist, an outreach worker/driver/safety coordinator, and a Roots Health Navigator/ Community Health Outreach Worker (CHOW) – works with the sickest individuals in homeless encampments and on the streets via multiple partnerships including those with City and County departments, other community based organizations, and relationships with key residents of the encampments themselves. The team conducts mobile outreach and street medicine services at least three days a week using a passenger bus converted to a clinic with an exam room, a draw station, and one intake/interview space. The STOMP outreach worker and navigator also go out on “non-clinical” days to deliver medication, medical supplies/durable medical equipment, and to transport patients to medical visits, surgery appointments, etc. (See East Bay Times article about STOMP: http://www.eastbaytimes.com/2016/01/22/drummond-homeless-doc-takes-stethoscope-to-the-streets).
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program: STOMP
Themes, Keywords & Tags: Homelessness
The Alliance Health Home Pilot
Roots Navigators, via our OaklandSTOMP Street Medicine program and Healthy Measures reentry program, work primarily with clients who are either homeless or at high risk of becoming homeless, including individuals returning to the community from incarceration – known to be at high risk of becoming homeless within the 90 days post-release. Our care team assesses housing stability, reviews all possible family and housing supports and resources, and creates a “plan A, B and C” regarding housing options prior to release from incarceration or other impending situational change.
Oakland STOMP works specifically with individuals living in homeless encampments and on the streets. A street medicine encounter begins with meaningful engagement with the STOMP team in the field, which ideally leads to engagement in clinical service on the mobile unit. While multiple visits with a patient in the field are often required before patients are trusting and confident enough to seek care at a fixed site, one of the primary goals of Oakland STOMP is to successfully link patients to care at a primary care medical home. To facilitate this transition, the Oakland STOMP team also provides clinical services at our fixed site one day a week via open-access scheduling, which provides dependable access to their familiar physician and care team. Once patients receive services within our facilities, they become increasingly comfortable with our staff and patients, and many establish care at Roots as their primary care medical home.
Over the past 12 months, the STOMP team has conducted 848 face-to-face physician visits in the field with 553 unduplicated patients. In addition, the team has distributed basic needs and harm reduction supplies (water, clothing, food, condoms, hygiene kits) to an average of 150 people per month. Outreach workers also provide an array of enabling services including benefits screening and enrollment; housing assistance; health and financial counseling; food assistance; dental and medical specialty referral; employment/on-the-job assistance; transportation assistance; substance use rehabilitation and counseling referrals; and referrals to SSI advocacy.
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program: STOMP
Themes, Keywords & Tags: Homelessness
Emancipators Initiative
An estimated 12.5% of Alameda County residents lived below 100% of the federal poverty level in 2013, according to the 2009-13 American Community Survey. Our target population lives in cities with some of the highest poverty rates in the county, including Oakland, where 20.5% live below the poverty level, Hayward with 14.4%, San Leandro with 10%, and Union City with 8.4%. AC-OCAP’s 2016-17 Community Action Plan describes income conditions faced by many Oakland families: “27% of Oakland’s residents had an annual income less than $24,999 and 39% of female- headed households with children under 5 years of age had incomes below the poverty level.”2 Staggering racial disparities in child poverty also persist with African Americans at 30%, compared with Whites at 6%.” Similarly, nearly one out of four (24.9%) individuals in Roots’ East Oakland service area live below the poverty; as a result, we are all too familiar with the magnitude of unmet needs compounded by no insurance, little income, and/or job insecurity. More than one in four of our service area residents above the age of 17 lack even a high school diploma. Age-adjusted death rates for diabetes and hypertension are at least 50% higher in our service area than in the state – health conditions that if diagnosed early and managed properly would not lead to premature death. Our service area is also home to the greatest concentration of supervised individuals (probation/parole), and comprises 7 of the top 10 stressor beats in Oakland, indicating higher rates of violent crime. Roots staff and board recognize that as the gap in resources and opportunities continues to grow, our target population will experience disproportionate impact – reinforcing what data and experience tell us: high poverty and unemployment correlate with lower quality of life, shorter life expectancy, lower educational attainment rates and greater exposure to violence and incarceration. Roots clients tell us that their greatest current needs are stable housing; culturally congruent/competent counseling, health care and mental health services; and training that leads to permanent and sustainable employment.
ref. ACOCAP_RFP_Response.pdf, 2017-2019 – Dan Abrahamson
Core Whole Health Care Area:
Program: Emancipators Initiative
Themes, Keywords & Tags: Unemployed; Homeless; Incarceration; Employment
Housing Case Management
Roots will provide Housing Case Management via Roots Health Navigators for recently homeless Oakland residents who have been placed into OPRI housing. Each Navigator will manage a caseload of up to 25 individuals/households at any given time. After reviewing and accepting initial referrals, clients will participate in a one-on-one assessment process to collaboratively design an Action Plan outlining goals and the steps most likely to result in a healthy transition to the community. All clients will receive daily, informal contact via telephone or text; will participate in barrier removal activities regarding employment and stabilization such as enrollment in Medi-Cal/ CalFresh; assistance with DMV barriers; clothing; job-seeking support; enrolling in substance abuse facility/sober living; linkage to primary and behavioral health care at Roots or other appropriate locations; and will participate in individual face-to-face meetings and group sessions as needed and delineated in the individual Action Plan. Over one year we anticipate serving 50-75 homeless individuals/households using intensive case management delivered by Navigators for an average of 6-12 months, depending on progress and stability, after which time they can continue to engage in services at Roots (primary care, behavioral health care, employment services, empowerment center, etc.) on an ongoing basis. Navigators form intense, long-term relationships with clients and are available to meet their urgent/emergent needs through mentorship and the provision of the resources listed above.
ref. PATH Narr_7_FINAL.docx, April 2018 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program: Housing Case Management
Themes, Keywords & Tags: Homeless; Housing
Housing Case Management
Roots’ Navigators provide case management, mentorship and supportive services at the time and place of need, through home visits, meeting in the community, attending appointments (medical, court, DMV, Probation/parole, etc.), as well as within the context of Roots health home. While the relationship with the Navigator remains a constant in the case management model, the level of intensity of care coordination is stepped up when patients destabilize or suffer a crisis, or stepped down when patients stabilize and become connected to services.
ref. PATH Narr_7_FINAL.docx, April 2018 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program: Housing Case Management
Themes, Keywords & Tags: Homeless; Housing
STOMP
Roots will expand mobile outreach services which initiate dialogue, establish rapport, and build trust with homeless individuals and families, resulting in connection to services that increase stabilization and improve outcomes. Our current methodology of providing outreach, mobile medical and wraparound services to Oakland’s homeless residents is highly effective in providing a secure bridge to needed services such as housing, medical and behavioral health treatment. However, the need is rapidly increasing, and our goal in expanding this work is to meet this increasing need.
Our mobile outreach team will consist of three to four team members, depending on time/location and activities. Team members include a minimum of two (up to three) outreach workers -one of whom is also the driver – and one Health Navigator, all of whom will connect with homeless Oakland individuals and families, engaging in field operations during morning and afternoon shifts with 1-2 shifts of 4 hours each, 5 days per week. Initial service hours will be Monday 9-5; Tuesday 10-2; Wednesday 9-5; Thursday 10-2; and Friday 9-5. As we assess our activities and specific needs at each site, we may modify our schedule accordingly, continuing to provide services a minimum of 32 hours per week (eight 4-hour shifts) over a minimum of 5 days per week.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Mobile Outreach; Homeless
STOMP
Mobile street outreach will promote community well-being through: distribution of basic needs and harm reduction supplies (food, water, hygiene supplies, blankets and first aid/wound care supplies), enrollment in benefits (Medi-Cal, CalFresh, etc.), and linkage to services (clinical, behavioral, SSI, substance use, housing, etc.).
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Mobile Outreach; Homeless
STOMP
Over one year we anticipate direct contact with at least 600 homeless individuals, with a minimum of 4,800 duplicated contacts. We will record encounter data as required for this scope of work – including for entry into HMIS – to meet program requirements, inform our own program revision, and for annual reporting to the Office of Statewide Health Planning as required of all CA Department of Healthcare Services licensed clinics.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Data; Homeless
STOMP
Roots’ mobile van will contact homeless individuals at designated sites throughout Oakland. Current service sites are determined by our extensive work with individuals at homeless encampments, underpasses and other locations where Oakland’s homeless reside. Our outreach schedule includes a rotation of prioritized sites in three regions: East Oakland, downtown Oakland, and West Oakland. We are in frequent communication with city and county staff regarding priority locations/situations/individuals, and often coordinate with other service providers to maximize impact and reduce duplication of efforts. We also receive a monthly list of encampment sites from CalTrans which aids our team in planning outreach and harm reduction activities as communities are relocated. For this scope of work, we anticipate also receiving and following a schedule set by the City of Oakland for blight abatement and posting, which will help shape our activities and outreach schedule.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Homeless
STOMP
All team members will be trained in de-escalation/conflict resolution and outreach safety. All Outreach Workers engage with individuals in encampments, streets, etc.; screen for basic needs; distribute food, water, and supplies; make individuals aware of available services; check eligibility and conduct new Medi-Cal and CalFresh (food stamps) enrollments; assist in identifying sites; and play a role in ensuring team safety. One team member, typically the outreach worker/driver, is the Safety Officer who takes the lead in ensuring a secure environment for the team and delegating other safety tasks/roles to team members. The Health Navigator is a trained Community Health Outreach Worker who provides service navigation, health/harm reduction education, and linkage to community resources such as mental health needs, SSI advocacy, legal barriers, ID/DMV, etc. The Health Navigator also can directly link clients to Roots’ Oakland STOMP medical team for medical/behavioral health concerns/crises.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Homeless; Staffing; Conflict; Resolution; Safety
STOMP
Through our Oakland STOMP team (funded via Alameda County Healthcare for the Homeless), we work with the sickest individuals in homeless encampments and on the streets. This proposed scope of work will allow us to expand our reach, engage with more homeless individuals, perform triage regarding the level of service intervention required, and provide or arrange for that intervention. Because Roots possesses the expertise to address the needs of the most unstable and vulnerable among the homeless, we are uniquely positioned to identify and address root causes that led to these conditions. This opportunity would allow us to design and implement solutions at a community/population level, impacting a larger number of individuals, while identifying those who are most unstable and linking them to services.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Homeless
STOMP
In 2015, Roots expanded our street outreach model by adding medical services, through implementation of our Oakland Street Team Outreach Medical Program (STOMP), a physician-led street outreach healthcare team serving the homeless across Oakland, funded by Alameda County Health Care Services Agency’s Health Care for the Homeless program. Our homeless services reflect the experience, expertise, and wisdom we have earned working with this population since our inception. Oakland STOMP reaches homeless Oakland residents through outreach, supply distribution, provision of medical care when needed, service navigation and by acting as a hub that links homeless individuals with a multitude of services. The outreach worker and navigators who staff the STOMP team provide follow-up for supportive/non-medical encounters to deliver wound care supplies, medications and durable medical equipment, and client transportation to specialty and surgery appointments. These repeated interactions, and our visibility and stability providing services to Oakland’s homeless residents, position us well to provide expanded outreach services to additional homeless residents, including those who may not have medical/clinical needs.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Homeless; Medical
General
Since its inception, Roots has served Oakland residents experiencing homelessness and unstable housing. In 2015, in partnership with the Alameda County Department of Public Health’s Healthcare for the Homeless Program, Roots built upon this work to implement the Oakland Street Team Outreach Medical Program (STOMP), a physician-led street outreach healthcare team serving the homeless across Oakland. The goal of Oakland STOMP is to seek and treat the sickest and most vulnerable among Oakland’s homeless population, preventing morbidity, mortality, and avoidable utilization of hospital and emergency systems. In order to accomplish this, the STOMP team has developed recognition and trust among Oakland’s homeless population, interacting with homeless residents in East Oakland, downtown Oakland and West Oakland. The team informs homeless residents about our services, distributes basic needs supplies, and builds rapport and trust as they interact in these communities. Often, multiple interactions with the same individual are required before the individual is trusting enough to avail themselves of medical services. These repeated interactions, and our visibility and stability providing services to Oakland’s homeless residents, position us well to provide expanded outreach services to more homeless residents, including those who may not have medical/clinical needs.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Homeless; Emergency Systems; Medical
Prop 47 Housing Assistance Support Services
Roots proposes that Prop 47 Housing Support funds will add value to our comprehensive integrative services and proven programs and rapidly build our capacity to respond to unmet needs for justice-involved adults with a serious mental illness (SMI) and/or substance use disorder (SUD) and those who are homeless or at-risk of homelessness.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Mental Illness; Substance Abuse; Homeless
Prop 47 Housing Assistance Support Services
Roots holds current contracts with Alameda County Health Care Services Agency and Alameda County Social Services Agency which require regular reporting using Results Based Accountability standards. Roots staff has extensive experience collecting and reporting quantitative and qualitative data via multiple platforms and systems including Cityspan for our work under the City of Oakland’s Oakland Unite; our annual Office of Statewide Health Planning (OSHPD) report required as a state licensed clinic; as well as data for Healthcare for the Homeless reporting to the Federal Uniform Data Systems (UDS).
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Partnerships; Homeless; Evaluation
Prop 47 Housing Assistance Support Services
Roots has also operated our Oakland Street Team Outreach Medical Program (Oakland STOMP) since August 2015, bringing clinical care and care coordination directly to Oakland’s unsheltered three days a week, including outreach, benefits enrollment, linkage to services and treatment, and life-saving medical care. Our care team takes a fully equipped mobile medical clinic to homeless encampments in East, West, and Downtown Oakland. In 2017 alone, we delivered 1,129 face-to-face medical visits to 797 unduplicated homeless individuals under the freeways and in the encampments of Oakland. Our STOMP team has developed a high level of credibility and trust among Oakland’s unsheltered by providing consistent, reliable, non- judgemental services at the time and place of need. Sixteen months ago, we established a walk-in clinic run by the STOMP team at our East Oakland main campus. We currently provide clinical services to a base of 60 patients through this 4 hour/week clinic, demonstrating that even the highest risk unsheltered individuals will avail themselves of services in a brick-and- mortar facility once a foundation of trust has been established.
Because of our success in building trust among Oakland’s unsheltered, and the accessibility of our East Oakland main campus, we were selected by the City of Oakland to join the newly- created Coordinated Entry System as the East Oakland Street Outreach provider. We employ 1.5 dedicated full-time equivalents as Certified Housing Assessors to complete and submit housing assessments on behalf of homeless individuals in East Oakland. Assessments are performed in the streets and encampments of East Oakland, as well as at our East Oakland main campus, via increach and the outreach activities of both our East Oakland street outreach team and Oakland STOMP.
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Medical Outreach; Homeless; Housing
Prop 47 Housing Assistance Support Services
As a member of the Coordinated Entry System with three Housing Assessors on our staff, we have been involved with the growing network of resources to help link clients to community resources to provide long-term housing stability, including the Housing Resource Centers, the Alameda County Housing Call Center, and linkages to Housing Navigators. In East Oakland, we have already formed an important partnership with East Oakland Community Project (the East Oakland Housing Resource Center), where our certified assessors are to conduct a warm hand-off and submit housing assessments.
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Housing; Homeless; Partnerships
Prop 47 Housing Assistance Support Services
Roots will implement Prop 47 Housing Assistance Support Services, administering funds to eligible, prioritized justice-involved individuals to assist them in overcoming the barriers of homelessness and housing instability. Housing has always been a top need expressed by the reentry clients we serve, and this need has only continued to increase. We are enthusiastic about the opportunity to be able to help address this necessity, working strategically and thoughtfully to prioritize those for whom we can make the greatest impact.
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Homeless; Housing; Reentry
Systems for Action: Systems and Services Research to Build a Culture of Health
Employment is one of the basic determinants of health, and influences the ability to obtain other determinants, such as food, and shelter. In East Oakland, there is a growing gap in resources for Oakland’s reentry residents. Many men lack basic skills to gain employment, and those with criminal records face even more barriers to employment. For the majority of employers, the cost of doing business is “high enough”, and they prefer not to take risks/incur costs by employing the “difficult to employ”. While there have been some promising programs that focus on formerly incarcerated individuals, including those addressing employment needs (Bloom et al., 2007; Bushway et al., 2012; Duwe, 2015; Newton et al., 2016) and providing wraparound housing services (Lutze et al., 2014), there are few cohesive programs that combine health and employment services, and provide “standard” outcomes with generalizable programmatic evaluations from which to learn best practices. Additionally, most employment and/or reentry programs do not have a sustainability model built into them.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Workforce; Reentry; Employment Homeless
OPUS Prize Foundation
Oakland Homecoming will provide a pathway to exit homelessness through: transitional housing, transitional employment in our social enterprise, and individualized intensive navigation (case management) to at least 20 unsheltered Oakland residents over one year. Oakland Homecoming builds upon our expertise working with Oakland’s unsheltered population, our extensive history providing navigation services to marginalized community members, our experience operating a transitional housing facility, and our successful workforce development social enterprise, by integrating aspects of each of these areas of work to implement Oakland Homecoming.
ref. Opus workplan_09082017 OPUS PRIZE FOUNDATION Work Plan, September 2017
Core Whole Health Care Area:
Program: Oakland Homecoming
Themes, Keywords & Tags: Homeless; Housing
OPUS Prize Foundation
Oakland Homecoming will provide a path to self-sustainability to homeless individuals who are ready and willing to engage in workforce development leading to permanent employment, and transitional housing leading to permanent housing. Roots Community Health Center has recently secured a site in Oakland to house seven individuals at a time.
Our leadership is committed to utilizing this housing to demonstrate our model of pairing transitional housing with transitional employment to create a path out of homelessness – all within the context of the primary care medical home, and a supportive relationship with their Roots Navigator. Roots Navigators are Oakland residents with a shared, lived experience that resonates with our patient/client community, and who obtain a Community Health Worker (CHW) Certification and/or Health Coaching Certification. Roots Navigators specialize in working with different focus populations, and are qualified in-part based on their life experience. Through one-on-one coaching and peer support, multi-disciplinary teamwork, leadership development, and, most importantly, authentic relationships with their clients, Navigators model and encourage positive, pro-social community and family engagement. Roots’ theory of change guides the Navigators’ work: “empowering those who have been marginalized with skills that enable them to engage positively on behalf of themselves and with their communities via wraparound services delivered in the context of a safe and therapeutic relationship, improves morale and self-efficacy, ensures successful integration/reintegration into society, and improves overall community health and well-being.”
ref. Opus workplan_09082017 OPUS PRIZE FOUNDATION Work Plan, September 2017
Core Whole Health Care Area:
Program: Oakland Homecoming
Themes, Keywords & Tags: Homeless; Housing; Peer Coaching; Community Health Worker
OPUS Prize Foundation
Oakland Homecoming focuses on equipping homeless individuals with employment skills, coupled with housing and wraparound support designed to facilitate a smooth transition to a stable, self-sustaining life. We are confident that given our expertise working with Oakland’s unsheltered residents, and our success providing on-the-job training and skill-building for individuals who have been marginalized from the workforce, we will be able to demonstrate an effective, replicable model for ending homelessness for employable individuals living on the streets. The 2017 Alameda County Point-in-Time Count identified 1,902 individuals living on the streets in Oakland. Fifty-seven percent of Alameda County homeless residents surveyed indicated that “money issues” were their primary reason for homelessness. Forty-two percent reported that rental assistance could have prevented their homelessness, and 36% said that employment assistance could have prevented them from being homeless. Oakland Homecoming is intended to identify and engage individuals living on Oakland’s streets who could transition to a stable life, with critical stabilizers – housing and employment – along with navigation and case management services.
ref. Opus workplan_09082017 OPUS PRIZE FOUNDATION Work Plan, September 2017
Core Whole Health Care Area:
Program: Oakland Homecoming
Themes, Keywords & Tags: Employment; Housing; Homeless
ASCEND BLO
Roots offers medical services for the unsheltered and workforce training to the hard-to-employ. Roots now hopes to establish temporary housing to transition select persons from Oakland’s homeless encampments into stable housing at night and job training, counseling, social navigation, during the day as a path to permanent stability. $145,000/year. No further TA needed.
ref. ASCEND BLO Accelerator Application_FINAL.docx – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Shelter; Housing
The Alliance Health Home Pilot
Oakland STOMP is designed to meet the needs of some of the most medically fragile members of our community: chronically homeless individuals with complex medical and mental health conditions. These high-risk individuals should be prioritized for rapid re-housing, permanent supportive housing or housing first, depending on their assessed needs as well as their/our ability to verify contacts with healthcare and law enforcement. Our STOMP team has received extensive training from Alameda County Healthcare for the Homeless / Everyone Home on the “Home Stretch” unified application process for housing, and is successfully navigating the process to obtain housing for our most at-risk patients. We have also developed a critical partnership with the TRUST Clinic, a partnership of Healthcare Services Agency, Behavioral Health Care Services, Social Services Agency and Lifelong Medical Care, which supports chronically disabled individuals with intensive psychiatry and medical treatment and housing placement along with expertly navigating the process to obtain federal disability approval (SSI). Once a week a TRUST Clinic outreach worker travels with our STOMP team and is introduced through a warm handoff to eligible clients. Whether via our partnership with the TRUST Clinic, or through our own resources in securing housing for clients, our team has the expertise, tools, relationships and perspective needed to identify and focus efforts on those who would most benefit from housing.
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program: STOMP
Themes, Keywords & Tags: Housing
The Alliance Health Home Pilot
Our focus on unsheltered/unstably housed individuals has necessitated our proactive involvement with multiple housing agencies, as well as the development of our own housing units. We work closely with shelters, transitional housing, permanent housing and permanent supportive housing, housing/legal advocates, and veteran-serving organizations such as Operation Dignity. Through a memorandum of understanding with East Oakland Community Project (EOCP), a homeless shelter located in East Oakland, Roots has secured dedicated beds reserved for patients who find themselves in need of emergency housing. In turn, Roots sends its enrollment counselors regularly to EOCP to educate the residents about services provided at Roots and enroll them into public benefits. As a result, and because of the close proximity of the two agencies, EOCP and Roots share many mutual clients and are able to link these individuals to one another’s services as needed. We also work with Bay Area Community Services, Abode, Volunteers of America, Men of Valor, Options, and many other housing agencies that serve specific unsheltered populations (reentry, addiction, etc.). Lastly, we are currently developing our own housing in Oakland’s Fruitvale neighborhood, which will be used to transitionally house individuals engaged in our workforce development initiatives beginning in February 2017. By coupling transitional housing with on-the-job training/employment, we will facilitate a transition into permanent housing, breaking the cycle of shelter/temporary housing to the streets.
Our ability to maintain effective partnerships with housing and other supportive nonprofits and government agencies is enabled by our long-standing commitment to providing timely access to high quality care. Roots has emerged as a valuable asset in the community, and an effective partner to community based organizations and public agencies who rely on our services. For example, Roots is the primary care medical home for the clients of many community based organizations such as transitional housing facilities, homeless shelters, legal aid entities and substance abuse facilities. In turn, Roots is able to refer its patients to these community resources as needed, generally via a warm handoff to an established point of contact. Roots recognizes the importance of maintaining these relationships and developing new ones in order to ensure our patients benefit from easily accessible wraparound services across the community.
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Housing
The Alliance Health Home Pilot
Care Services Agency Health Care for the Homeless and Behavioral Health Housing Services Office. We also work with City of Oakland Department of Human Services Community Housing Services Division, including their rapid rehousing program. Lastly, we are in active conversations with Alameda County Housing and Community Development regarding our transitional housing development, and with Behavioral Health Housing to provide navigation services to an East Oakland housing development for individuals with severe mental illness.
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program:
Themes, Keywords & Tags: Housing
Bridging the Gap: Reducing Disparities in Diabetes Care
Key partners in ACDDRI—including ACPHD, Roots, and TVHC—have extensive expertise in deploying paraprofessionals into these communities, supporting underserved patients and families in navigating health insurance and access to care, as well in finding needed nutrition and economic supports. Roots has focused on the needs of African Americans who are homeless and/or re-entering the East Oakland community from incarceration. Roots’ multidisciplinary teams include Patient navigators who assist clients in affordable housing options, employment, benefits and health coverage enrollment, as well as in accessing health care. TVHC has centered its community outreach through its Promotoras de Salud program in the Latino community of Southern Alameda County, including the Ashland/Cherryland area, an area that has one of the County’s largest re-entry populations. TVHC recruits and works with a network of promotoras who serve as health promoters in their neighborhoods and schools, largely serving a monolingual Spanish-speaking population. While paraprofessionals in the targeted clinics and communities have extensive experience with helping families navigate a range of health and social service systems, they have not yet been trained or deployed as full members of diabetes or chronic disease care teams. To fill this unmet need, ACDDRI will expand on these demonstrably successful models to train a cross-agency cohort of paraprofessionals in diabetes self-management. In terms of food access, ACDDRI will build on and adapt a range of innovative programs focused on nutrition and health equity developed by ACPHD in partnership with a range of community-based clinics and partners. ACPHD’s Community Health Services Division includes not only the Chronic Disease Program (including the Diabetes program) but also Nutrition Services and the WIC program. ACPHD has long convened the County Nutrition Action Plan for Alameda County, coordinating nutrition education activities, especially those that prioritize low-income communities such as the targeted neighborhoods, among public agencies and community-based partners.
For example, in 2011-2014, ACPHD’s health equity and nutrition services teams coordinated a large-scale effort called Food to Families (F2F), an innovative partnership project, funded for three years by the Kresge Foundation, with overarching goals to 1) transform the food landscape; 2) provide local economic and employment opportunities for young adult residents; and 3) to reduce the risk of obesity and overweight in West Oakland and Ashland/Cherryland. ACPHD partnered with the County-run social enterprise Dig Deep Farms and Produce and TVHC in Ashland Cherryland and with Mandela Marketplace and another FQHC in Oakland. F2F developed interventions including Produce Rx, a clinic-based program to provide pregnant women with produce “prescriptions” connecting them with local food access points and consumer training developing skills around food purchase, preparation, storage and healthy life skills. Successes included strong partnerships between community-based organizations, the FQHC’s, and ACPHD; enhanced interventions; strong participation by pregnant women and their families; the creation of one model adapted to serve two different communities; integration of young adults into staffing of partner organizations. For ACDDRI, we envision adapting the Produce Rx model to meet the needs of people with diabetes, working with a similar range of community-based food distribution, farm stands/farmers markets, and community-supported agriculture partners.
Core Whole Health Care Area:
Program: ACDDRI
Themes, Keywords & Tags: Housing; Diabetes; WIC; Paraprofessionals; Employment; Food Access
Empowerment Center
The primary goal of the Empowerment Center is to address economic stability through client preparation for meaningful employment, stable housing, upward mobility and enhanced family life. The Empowerment Center is an integral component of our Whole Health model, where economic barriers are addressed simultaneously with planning for/seeking housing. We assist clients in obtaining and maintaining employment and housing by encouraging effective planning and sound decision-making. The center offers a variety of resources, including a job and housing resource board, resume development workshops, and interview preparation. We currently hold housing workshops which include guided self-assessment on housing readiness, tips and tools for seeking housing, a review of tenant rights, and assessment and plan design to remove barriers to obtaining housing (credit history, felony record, etc.). We also offer independent living counseling on topics such as nutrition/shopping, household budgeting, grooming and hygiene. Clients will also have access, through their Navigator, to flexible funds that can be used to support urgent and move-in costs to facilitate housing retention.
ref. PATH Narr_7_FINAL.docx, April 2018 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program: Empowerment Center
Themes, Keywords & Tags: Housing; Empowerment; Employment
STOMP
The work of Roots Navigators is informed by cross-training, intersection and collaboration with Roots’ STOMP team, composed of our Street Medicine Director (a primary care physician), a Medical Assistant/Phlebotomist, an outreach worker/driver/safety coordinator, and one Roots Health Navigator/Community Health Outreach Worker (CHOW). This team works with the sickest individuals in homeless encampments and on the streets via multiple partnerships including those with city and county departments, other community based organizations, and relationships with key residents of the encampments themselves. The team conducts mobile outreach and street medicine services at least three days a week using a passenger bus converted to a clinic. (See East Bay Times article about STOMP: http://www.eastbaytimes.com/2016/01/22/drummond-homeless-doc-takes-stethoscope-to-the-streets). Oakland STOMP patients are linked to Roots for additional case and care management, including leading/facilitating the process of obtaining housing through Home Stretch. Navigators continue to support clients after they are housed, ensuring that they are able to perform tasks of daily living, and that they are able to maintain their housing.
ref. PATH Narr_7_FINAL.docx, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Housing
Housing Case Management
For this scope of work, Housing Case Management Services will be provided on-site at Roots, in the community, or at the client’s residence. Roots will link referrals to case management and service navigation services, and assessment and counseling services from a licensed mental health professional if needed/wanted. Roots’ goal for this work is to extend our culturally-defined, trauma-informed behavioral health and wraparound services to residents recently transitioning into housing from homelessness. Our goal is undergirded by Roots’ theory of change: that empowering those who have been marginalized with skills that enable them to engage positively on behalf of themselves and with their communities via wraparound services delivered in the context of a safe and therapeutic relationship, improves morale and self-efficacy, ensures successful integration/reintegration into society, and reduces and improves mental health conditions. Roots enacts this theory of change – whether in the clinical setting, in service navigation, or in workforce development – and will work specifically to increase housing retention for this focus population.
ref. PATH Narr_7_FINAL.docx, April 2018 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program:
Themes, Keywords & Tags:Housing; Case Management
Proposition 47 Housing Assistance Support Services
We propose to pair this critical Housing Assistance Support to our existing HealthyMeasures Initiative which provides Navigation and Whole Health services to the reentry population. We are encouraged by this opportunity to enhance needed supports for the many formerly incarcerated Oakland residents who are expected to successfully reintegrate into their families and communities. The proposed program joins our expertise as primary care medical home dedicated to serving the target population with our experience developing and executing successful workforce and barrier removal initiatives designed to support the needs of those reentering society after incarceration. Our approach combines physical and behavioral healthcare with complementary wraparound services enhanced by health navigation/case management to access benefits and build linkages to appropriate services; the addition of Housing Assistance support would be a natural complement to this work.
Core Whole Health Care Area: Navigation
Program: Healthy Measures
Themes, Keywords & Tags:Housing; Whole Health; Reentry
Proposition 47 Housing Assistance Support Services
Securing basic needs including food, stable shelter, safe environments, and social connectedness are necessary for effective behavioral/mental health self-management and avoidance of unnecessary health services utilization. Roots Community Health Center has established intake and assessment tools and processes that evaluate social determinants of health, establishing a baseline and enabling ongoing monitoring of the stability of each client. In addition to administering the intake and life assessment tools, Navigators are trained to administer Screening, Brief Intervention, and Referral to Treatment (SBIRT), the Alcohol Use Disorders Identification Test (AUDIT), Drug Abuse Screening Test (DAST), and the PHQ-9 depression screening instruments to assist in identifying mental health challenges, substance use disorders and corresponding need for supports. Navigators use results to proactively connect patients with community resources as well as internal or external referrals. Information gleaned from the assessment assists in determining frequency and intensity of services, appropriate assignment of clients to Navigators, and efficient monitoring of client progress. For this scope of work, we will utilize our data systems to correlate baseline status with eligibility requirements, develop prioritization and interventions, and evaluate with respect to health/mental health and housing outcomes in an effort to achieve the greatest impact.
Core Whole Health Care Area: Navigation
Program:
Themes, Keywords & Tags: Housing; Reentry; Employment; Substance Abuse; Food Access; Whole Health
Proposition 47 Housing Assistance Support Services
Another critical component of Healthy Measures that would support the proposed scope of work is our multi-disciplinary case conferencing where we discuss the status, goals and interventions/ plans for each navigated client. This multidisciplinary team includes the Director of Navigation Services, Navigator Manager, a mental health provider, a program administrator and our health navigators. Since the implementation of our work through the Coordinated Entry System, we are in the process of adding housing assessors to this existing infrastructure where appropriate. At these sessions, care plans, client progress and outcomes are discussed to provide the most meaningful array of services and supports to sustain progress towards achieving and maintaining stability; adding Housing Assistance to our existing array of resources and services has tremendous potential to contribute to the overall stability of prioritized clients.
Core Whole Health Care Area: Navigation
Program: Healthy Measures
Themes, Keywords & Tags: Housing; Mental Health
Proposition 47 Housing Assistance Support Services
We employ 1.5 dedicated full-time equivalents as Certified Housing Assessors to complete and submit housing assessments on behalf of homeless individuals in East Oakland. We are positioned favorably to bridge the gap in these much needed services by conducting housing assessments in the streets and encampments of East Oakland, securely linking individuals to the Housing Resource Centers and housing navigators when needed, and regularly referring clients to housing providers to coordinate care and ensure clients receive the services and supports they need to achieve and maintain Whole Health. Importantly, our outreach workers maintain long-term relationships with unsheltered individuals, facilitating their continued and successful engagement in programs and services. We also have several referral relationships with mental health and substance use disorder providers including Cherry Hill, Options Recovery, Sausal Creek, the East Bay Community Recovery Project and Pathways to Wellness. We provide both warm handoffs and Navigated supportive services and linkages.
Core Whole Health Care Area: Navigation
Program:
Themes, Keywords & Tags: Housing; Mental Health; Partnerships
Mental Health Prevention and Early Intervention (PEI) Services in Sobrante Park
Roots collaborates across the city and county with the Mayor’s Safety Impact Table (which is focusing on projects in East Oakland), the Justice Reinvestment Coalition, the Racial Equity Task Force, and the African American Steering Committee for Health and Wellness. Roots staff are active participants in several East Oakland place-based initiatives, including Violence Prevention Initiatives for Eastmont and Sobrante Park, as well as initiatives overseen by the Alameda County Public Health Department including Oral Health, Educational Care Coaching, tobacco policy advocacy and cessation, and diabetes education. Roots also provide significant direct service in the area via our Health Care Services Agency-funded street medicine/mobile clinic, and Hepatitis C treatment program (at the 105th and Pearmain needle exchange). Roots also performs housing assessments on the streets of East Oakland through our relationship with the City and County via the newly-launched Coordinated Entry System.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Housing; Mental Health; Partnerships; Reentry; Hepatitis C
Mental Health Prevention and Early Intervention (PEI) Services in Sobrante Park
Securing basic needs including food, stable shelter, safe environments, and social connectedness are necessary for effective behavioral self- management and avoiding unnecessary health services utilization. Roots has established intake and assessment tools and processes that evaluate social determinants of health, establish a baseline, and enable ongoing monitoring of the stability of each client. Upon intake, Navigators utilize our Vital Signs screening tool to examine individuals and families in 9 domains of wellness and four stages of risk. This tool delineates strengths and protective factors as well as risks and barriers the families and individuals face. In addition to administering our intake and life assessment tools, Navigators administer Screening, Brief Intervention, and Referral to Treatment (SBIRT), the Alcohol Use Disorders Identification Test (AUDIT), Drug Abuse Screening Test (DAST), and the PHQ-9 depression screening instruments to help identify mental health challenges, substance use disorders and corresponding need for supports. For this scope of work, Roots will integrate prevention and early intervention family case management into our already robust intake and assessment processes. Family Navigators are trained to perform developmental screenings utilizing the Ages and Stages Questionnaire – Third Edition (ASQ-3) and ASQ: Social-Emotional Milestones and other holistic measures to determine environmental factors and barriers to family wellness.
Core Whole Health Care Area: Navigation
Program: Navigator Initiative
Themes, Keywords & Tags: Housing; Mental Health; Intake; Assessment; Food Access
Sobrante Park Narrative
Navigators use results of the intake and assessment process to proactively connect patients with internal as well as external resources. Information gleaned from the assessment helps Navigators determine the appropriate frequency and intensity of services, choose which clients to pair with which Navigators, and how best to monitor client progress. We utilize our data systems to correlate baseline status with service eligibility requirements, develop prioritization and interventions, and evaluate health/mental health and housing outcomes to assess (and improve) our impact.
Roots Navigators offer a wide array of services, including: case management, service navigation, Medi-Cal enrollment/renewal, CalFRESH (food stamp) enrollment/renewal, screening for and connection to onsite legal services including record clearing remedies, and distribution of essentials and basic supplies, such as bus passes, diapers (adult and child), car seats, and hygiene kits. Our Empowerment Center, co-located with our East Oakland clinic, includes a computer lab for resume development, job search and housing search, and onsite hiring events hosting a broad range of employers. Roots will soon launch a food pantry in collaboration with the Alameda County Community Food Bank to address high levels of food insecurity encountered by our clients. We propose adding the Time Banking platform to our economic empowerment services to promote meaningful engagement, and to earn social capital and time-based currency as ways to achieve economic stability. While we understand that employment opportunities for adults are not within the scope of this RFP, we consider poverty to be a profound barrier to wellness for our community. Therefore, we will help clients who could benefit from apprenticeships – to be provided in-kind. Participants will earn stipends as well as credit in the time bank, while developing meaningful skills in light manufacturing, outreach, health administration, and retail/customer service at our Roots and Clean360 sites.
ref. RFP#HCSA-900218_Sobrante Park_narrative.pdf, March 2018 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program: Navigator Initiative; Empowerment Center; Emancipators Initiative
Themes, Keywords & Tags: Housing; Reentry; Clean360
AB 109 Reentry and SSI Advocacy Population Case and Care Management Services
Our HealthyMeasures Initiative is particularly effective as clients navigate major life transitions, including reentry to the community after incarceration. This model has reliably been shown to improve mental and physical health outcomes in clients with mental illness. In our proposed program, we will adapt our model to accommodate case management time-limitations and targeting of the reentry population with SMI, which will allow us to provide services to a larger number of SMI individuals reentering the community. The focus of our case and care management in this adapted Behavioral Case Management Model will be to provide individuals with continuity of care from jail to the community, enrolling them in benefits and services for which they qualify, and facilitating linkages to stabilizing resources and long-term care. Case and care management will occur within the context of the patient-centered health home, which we anticipate – as in our current program – clients will continue to access following graduation from case management. This feature provides a foundation of stability and continuity of care, counteracting anticipated self-doubt and institutional mistrust exhibited by reentry individuals.
Core Whole Health Care Area: Navigation
Program: Healthy Measures
Themes, Keywords & Tags: Housing; Reentry; Mental Health
AB 109 Reentry and SSI Advocacy Population Case and Care Management Services
Mitigating challenges through cultural and community competence. Roots leadership agrees that in order for this population to meaningfully engage in ongoing primary, preventative and mental health care, their initial experiences upon entering the medical system must build trust and create a partnership between client and staff to overcome the multitude of barriers that exist. Engaging these patients on the ground-level when they enter the system is crucial to ensuring ongoing care. Thus we have built on our early work to bring vitally needed tools for health and stabilization to men reentering society from prison and those with substance abuse and mental health issues, through implementation of HealthyMeasures Initiative, a strong case/care management model staffed by a team that includes Roots Health Navigators (RHNs: peers who have all been incarcerated) who play a lead role in building trusting relationships and individualized plans with patients/clients, while ensuring they feel safe, comfortable and supported by our team. Clients often contact their RHN and drop by Roots to check in, even without an appointment; we believe that this level of engagement is due in part to our selection, training and support of RHNs with shared experiences and a true connection to community. RHNs build trust that facilitates their ability to obtain detailed information from clients including family contact information, where they hang out, and what they do when they are under stress. RHNs take an assertive approach to staying connected, via home visits and active outreach, especially during times of crisis. We frequently receive information from others involved in clients’ lives, such as probation officers, service providers and family members. And while these individuals/organizations understand our duty to protect client privacy, they are often moved to share information with us that assists in client care.
Core Whole Health Care Area: Navigation
Program: Healthy Measures
Themes, Keywords & Tags: Housing; Reentry; Mental Health; Navigators
Mental Health Prevention and Early Intervention (PEI) Services in Sobrante Park
Securing basic needs including food, stable shelter, safe environments, and social connectedness are necessary for effective behavioral self- management and avoiding unnecessary health services utilization. Roots has established intake and assessment tools and processes that evaluate social determinants of health, establish a baseline, and enable ongoing monitoring of the stability of each client. Upon intake, Navigators utilize our Vital Signs screening tool to examine individuals and families in 9 domains of wellness and four stages of risk. This tool delineates strengths and protective factors as well as risks and barriers the families and individuals face. In addition to administering our intake and life assessment tools, Navigators administer Screening, Brief Intervention, and Referral to Treatment (SBIRT), the Alcohol Use Disorders Identification Test (AUDIT), Drug Abuse Screening Test (DAST), and the PHQ-9 depression screening instruments to help identify mental health challenges, substance use disorders and corresponding need for supports. For this scope of work, Roots will integrate prevention and early intervention family case management into our already robust intake and assessment processes. Family Navigators are trained to perform developmental screenings utilizing the Ages and Stages Questionnaire – Third Edition (ASQ-3) and ASQ: Social-Emotional Milestones and other holistic measures to determine environmental factors and barriers to family wellness.
…Navigators use results of the intake and assessment process to proactively connect patients with internal as well as external resources. Information gleaned from the assessment helps Navigators determine the appropriate frequency and intensity of services, choose which clients to pair with which Navigators, and how best to monitor client progress. We utilize our data systems to correlate baseline status with service eligibility requirements, develop prioritization and interventions, and evaluate health/mental health and housing outcomes to assess (and improve) our impact.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Intake; Assessment; Food Access; Housing; Mental Health
The Alliance Home Health Pilot
Since our inception, Roots has prioritized unprecedented access to primary care services, particularly at the time of a critical transition. As a result, we have become a reliable and responsive partner to our local hospitals and emergency rooms, accommodating post-Emergency Department (ED) and post-hospital follow-up appointments in a timely manner. In addition, for the past year Roots has provided effective interventions and intensive case management to individuals being released from the emergency department or hospital following a gun-related or gang related injury through a partnership with the City of Oakland and Ceasefire. Our OaklandSTOMP mobile medical unit (see 2 below for greater detail) prevents ED and hospital visits on a daily basis by providing care at the time and place of need, including transportation for specialty appointments, surgery, etc. Our STOMP team works closely with Alameda County Medical Center’s ED and hospital staff to provide wraparound support for our patients and ensure that they receive care in the most appropriate setting. While we continue to work to obtain real-time information regarding patient ED visits and hospitalizations to enhance care coordination, we have begun collecting self-reported data regarding ED/hospital visits upon intake and post-engagement with Roots. While our data remains preliminary, it is clear that upon linking to Roots as the primary care medical home, the overwhelming majority of our patients cease to utilize the emergency department as their source of primary/episodic care. And as they receive support from the care team and build their own skills in self-advocacy, primary care utilization continues to increase while inappropriate ED use diminishes. Our expertise and success in reducing inappropriate utilization for some of our community’s “hardest to reach” positions us well to increase the numbers of this target population into our care and case management model, and to implement formal analysis of utilization data to help inform program design and implementation.
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Care Model: Navigation
Program: STOMP
Themes, Keywords & Tags: Emergency Room, STOMP
The Alliance Home Health Pilot
Since its inception, Roots has served Oakland residents experiencing homelessness and unstable housing. In 2015, in partnership with the Alameda County Department of Public Health’s Healthcare for the Homeless Program, Roots’ built upon this work to implement the Oakland Street Team Outreach Medical Program (STOMP), a physician-led street outreach healthcare team serving the homeless across Oakland. Our homeless services reflect the experience, expertise, and wisdom we have earned working with this population. In the past year, OaklandSTOMP has reached thousands of homeless Oakland residents through outreach, supply distribution, provision of medical care when needed, and by acting as a hub organization that links homeless individuals with a multitude of services. We are a key partner in the County’s network of health centers and community based organizations that increase access and improve care for homeless individuals, and are one of two organizations in the County contracted to provide Street Medicine.
The STOMP team, composed of our Street Medicine Director (a primary care physician), a Medical Assistant/Phlebotomist, an outreach worker/driver/safety coordinator, and a Roots Health Navigator/ Community Health Outreach Worker (CHOW) – works with the sickest individuals in homeless encampments and on the streets via multiple partnerships including those with City and County departments, other community based organizations, and relationships with key residents of the encampments themselves. The team conducts mobile outreach and street medicine services at least three days a week using a passenger bus converted to a clinic with an exam room, a draw station, and one intake/interview space. The STOMP outreach worker and navigator also go out on “non-clinical” days to deliver medication, medical supplies/durable medical equipment, and to transport patients to medical visits, surgery appointments, etc. (See East Bay Times article about STOMP: http://www.eastbaytimes.com/2016/01/22/drummond-homeless-doc-takes-stethoscope-to-the-streets).
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Care Model: Navigation
Program: STOMP
Themes, Keywords & Tags: Homelessness, STOMP
The Alliance Home Health Pilot
Roots Navigators, via our OaklandSTOMP Street Medicine program and Healthy Measures reentry program, work primarily with clients who are either homeless or at high risk of becoming homeless, including individuals returning to the community from incarceration – known to be at high risk of becoming homeless within the 90 days post-release. Our care team assesses housing stability, reviews all possible family and housing supports and resources, and creates a “plan A, B and C” regarding housing options prior to release from incarceration or other impending situational change.
Oakland STOMP works specifically with individuals living in homeless encampments and on the streets. A street medicine encounter begins with meaningful engagement with the STOMP team in the field, which ideally leads to engagement in clinical service on the mobile unit. While multiple visits with a patient in the field are often required before patients are trusting and confident enough to seek care at a fixed site, one of the primary goals of Oakland STOMP is to successfully link patients to care at a primary care medical home.
To facilitate this transition, the Oakland STOMP team also provides clinical services at our fixed site one day a week via open-access scheduling, which provides dependable access to their familiar physician and care team. Once patients receive services within our facilities, they become increasingly comfortable with our staff and patients, and many establish care at Roots as their primary care medical home. Over the past 12 months, the STOMP team has conducted 848 face-to-face physician visits in the field with 553 unduplicated patients. In addition, the team has distributed basic needs and harm reduction supplies (water, clothing, food, condoms, hygiene kits) to an average of 150 people per month. Outreach workers also provide an array of enabling services including benefits screening and enrollment; housing assistance; health and financial counseling; food assistance; dental and medical specialty referral; employment/on-the-job assistance; transportation assistance; substance use rehabilitation and counseling referrals; and referrals to SSI advocacy.
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Care Model: Navigation
Program: STOMP
Themes, Keywords & Tags: Homelessness, STOMP
Alameda County Diabetes Disparities Reduction Initiative
Roots offers a variety of case management and care coordination programs and services that use paraprofessionals known as Roots Navigators. The clinic has expanded on early work with reentry men and those with substance abuse and mental health issues, through implementation of the HealthyMeasures Initiative, a strong care/case management model, and OaklandSTOMP, a mobile clinic which targets medically fragile, chronically homeless individuals. Both Healthy Measures and Oakland STOMP utilize Roots Health Navigators who build trust that facilitates their ability to obtain detailed patient information, including family contacts, where they hang out, and what they do when they are under stress. Navigators are assertive in staying connected, via home/encampment visits and active outreach, especially during times of crisis. TVHC’s dedicated Community Health Education Department is committed to empowering its community through the provision of culturally competent and linguistically appropriate information, education and support. By listening with respect to the specific needs of the community we serve as ambassadors to build and sustain community partnership in order to facilitate action that results in increased awareness, healthier lifestyles and social change.
Since 1999, TVHC’s Promotoras de Salud program has engaged community health educators to recruit and work with a network of adult community volunteers who serve as health promoters in their neighborhoods and schools. The promotoras are trained in leadership, diseases prevention and outreach including sessions such as planning, conducting a meeting, conducting a presentation and health topics about the importance of immunizations chronic diseases prevention, cancer detection awareness, mental health early prevention and other based on county and community needs. They reach other Latino families through by conducting local community level interventions such as presentations, tablings, attending local health fairs, offering peer and door-to-door counseling, and/or teaching chronic disease self-management.
ref. AAH Response_FINAL_2017 The Alliance Health Home Pilot, 2017 – Dan Abrahamson
Core Care Model: Navigation
Program: ACDDRI
Themes, Keywords & Tags: Diabetes, STOMP
Hepatitis C Screening and Treatment
Roots utilizes a mobile clinic to expand our reach, especially among the homeless, through OaklandSTOMP (Oakland Street Team Outreach Medical Program), supported by AC Department of Public Health. Last year we brought clinical services to 279 homeless Oakland residents via 512 visits, providing them with a secure bridge to a medical home they will utilize. We have gained significant expertise through this effort, and client numbers remain strong as we continue with 20+ hours of street medicine per week. A weekly walk-in clinic at Roots has also been added to facilitate linkage and establishment of a primary care medical home (in-clinic visits are not counted in the numbers above). Clinical exams and lab work can be done directly in the mobile clinic, bypassing the need to be physically present to a clinic and providing direct access to care at the time and place of need. In addition to serving unsheltered encampments, we also regularly provide clinical services at needle exchange sites, which attract both sheltered and unsheltered individuals, and allow for continuity in visits given the predictability of clientele.
Core Care Model:
Program: HealthSTATS, STOMP
Themes, Keywords & Tags: HIV, Hepatitis C, STOMP
STOMP
Street Outreach. Implemented in 2015, Roots also supports a Street Team Outreach Medical Program (STOMP) that brings a medical team to homeless people across Oakland three times a week and offers benefits enrollment, linkage to services and treatment, and medical care. In the past 24 months, 823 homeless patients have received treatment; over 1900 face-to-face doctor visits have occurred; care and over 2400 basic needs supplies have been distributed. STOMP meets people “where they’re at” in each encounter – both physically, and in terms of their readiness to engage in their own health and well-being. By building long-term relationships and reducing harm, we reach homeless residents who are marginalized from traditional healthcare, while improving the health of our community overall. Because the STOMP patient base has rapidly expanded, we now offer a weekly walk-in clinic at Roots’ main site in East Oakland.
ref. GG_accepted
Core Care Model:
Program: Outreach, STOMP
Themes, Keywords & Tags: STOMP
IRUSA Narrative
Our work is also informed by our experience serving Oakland’s most medically fragile, homeless residents through our Oakland Street Team Outreach Medical Program (STOMP), a physician-led street outreach healthcare team. Funded by Alameda County Health Care Services Agency’s Health Care for the Homeless program, we provided 1,133 medical visits for the sickest and most vulnerable residents in Oakland’s encampments and on the streets over the past year. By bringing critical medical services to homeless camps themselves, these residents are able to access both urgent and primary care medical services that they would otherwise be without. STOMP reaches homeless Oakland residents through outreach, supply distribution, provision of medical care when needed, service navigation and a critical link for homeless individuals to a multitude of services. Through this work, we are gaining tremendous insight into the causes and impacts of homelessness, which is informing our intervention strategies. While many unsheltered individuals we encounter are severely impacted by unstable behavioral conditions or substance use issues, there are increasing numbers of homeless individuals who are employable and ready to act on opportunities that will lead to self-sustainability.
ref. IRUSA Narrative
Core Care Model:
Program: STOMP
Themes, Keywords & Tags: STOMP, Street Team, Outreach, Los Angeles
STOMP
The majority of program participants will hail from Roots’ current patient and client base. We anticipate that this will include a significant number of unsheltered patients that utilize Roots Street Team Outreach Medical Program (STOMP) mobile clinic. In 2017 STOMP conducted 1,129 face-to-face provider visits to 749 unduplicated patients in encampments/under freeways, of whom 43% had substance use disorder (SUD), mental illness, or both. Over 2.5 years, Roots providers have diagnosed 283 (29.7%) STOMP patients with SUD, including patients screened eligible and ready for MAT. These Roots primary care patients are currently referred to Alameda Health System (AHS) for MAT services. Roots (at the edge of East Oakland) and AHS (in the middle of Oakland) already have been discussing how to add navigator support to facilitate MAT access and retention across the city as well as MAT coordination at the jail; we will build upon this existing partnership and develop the infrastructure to implement these strategies.
ref. MAT FOA_07082018, July 2018
Core Care Model:
Program: STOMP, MAT Program
Themes, Keywords & Tags: STOMP, Street Team, Outreach, Substance Abuse